Friday, July 30, 2010

While Dr. Don Berwick, Obama's recess appointee to head CMS, speaks of Britain's NHS in glowing if not poetic and outlandishly laudatory terms,Britain's Prime Minister who has actually studied a report about NHS failings presents a different portrait . See here for the white paper on the NHS.

Here is one except from that report:... the NHS has achieved relatively poor outcomes in some areas. For example, rates of mortality amenable to healthcare, rates of mortality from some respiratory diseases and some cancers, and some measures of stroke have been amongst the worst in the developed world.

"Worst in the developed world" Berwick began his remarks celebrating the 60th anniversary of the NHS with this:

"I am romantic about the NHS; I love it. All I need to do to rediscover the romance is to look at health care in my own country."

His expressed infatuation for the single payer,centrally planned health system of Great Britain is obvious.What is less obvious is how he (or anyone) could reconcile those views with his self admitted radical views of patients primacy.

Dr.RW takes on this daunting task in his recent blog posting (see here) and using in part material from a 2007 IHI publication (see here) he provides insight into Berwick's thinking about reconciling conflicting aims.

Everyone ,physicians,patients,anyone who might become a patient should read about the "goals" that Berwick's organization advocates for a health care system.Then consider on what planet or in what alternative reality those aims could be actually accomplished by governmental central planning.It makes Will Roger's quote " Boil the oceans" ( to get rid of German U-boats ) seem practical.

Dr RW says this about their formulation:

'Grandiose, nebulous and intrusive are adjectives that come to mind." I think he is too kind.

Saturday, July 24, 2010

Go here to see the labyrinth of provisions, regulations, deadlines,subsides and cross subsidies from the hundreds of thousands of words from PPACA that will transform American medicine. Read through it and try and see who gains and who loses. I suggest the countless details defy a comprehensive analysis. It will be years before the the unintended consequences can begin to be sorted out.Did the advocates for Obama care from AMA and ACP and other medical organizations who claim a victory for "social justice" have a clue about what the bill really contained? I suggest they understood even less that some of legislators who admitted they had not even read the bill.Further, many of the operational particulars have not yet been defined.That is a work in progress by the numerous governmental agencies who are now beset upon by the various lobbying interests(known euphemistically as stakeholders ).

Perusing the chart makes me wonder why there is so so much detail,why so many elements and provisions are there ,why laws are crafted to be so long and so opaque and why are so many agencies and governmental entities are necessary to carry out any stated goal.

"[O]ur ruling class’s standard approach to any and all matters, its solution to any and all problems, is to increase the power of the government – meaning of those who run it, meaning themselves, to profit those who pay with political support for privileged jobs, contracts, etc."

Simply put, it has to be long and detailed and governmental agencies have to empowered to make many discriminatory decisions so that the folks in power can ensure who is that profits and who it is that picks up the tab. A statute's mind-boggling length and opacity serves to obscure what is happening.

Senator Baucus apparently really knew what the health care bill was all about even though he likely could not detail exactly what all the provisions were when he said in his exuberant candor after the bill was passed:

"Too often, much of late, the last couple three years, the mal-distribution of income in America is gone up way too much, the wealthy are getting way, way too wealthy and the middle income class is left behind," he said. "Wages have not kept up with increased income of the highest income in America. This legislation will have the effect of addressing that mal-distribution of income in America."

Right, it was all about redistribution of wealth which it just so happens is Dr. Don Berwick's desire as well as regards health care in America expressed in this quote from Berwick:

"...and that any health care funding plan that is just, equitable, civilized, and humane must – must – redistribute wealth from the richer among us to the poorer and less fortunate.

Monday, July 19, 2010

An essay that is receiving much attention as it should is available here .The author is Angelo M. Codevilla, a professor emeritus from Boston University. His characterizations of the" Ruling Class" and the "Country Class" is in the least thought provoking. I quote from the section labeled " Dependence Economics" with my bolding added:

"By taxing and parceling out more than a third of what Americans produce, through regulations that reach deep into American life, our ruling class is making itself the arbiter of wealth and poverty. While the economic value of anything depends on sellers and buyers agreeing on that value as civil equals in the absence of force, modern government is about nothing if not tampering with civil equality. By endowing some in society with power to force others to sell cheaper than they would, and forcing others yet to buy at higher prices -- even to buy in the first place -- modern government makes valuable some things that are not, and devalues others that are. Thus if you are not among the favored guests at the table where officials make detailed lists of who is to receive what at whose expense, you are on the menu. Eventually, pretending forcibly that valueless things have value dilutes the currency's value for all. Laws and regulations nowadays are longer than ever because length is needed to specify how people will be treated unequally. For example, the health care bill of 2010 takes more than 2,700 pages to make sure not just that some states will be treated differently from others because their senators offered key political support, but more importantly to codify bargains between the government and various parts of the health care industry, state governments, and large employers about who would receive what benefits (e.g., public employee unions and auto workers) and who would pass what indirect taxes onto the general public."

Treating people differently seems to be the essence of "social justice" for which supporters of Obamacare claim a victory.

While the leaders of AMA and ACP ( and other medical organizations as well) announced proudly they had a seat at the adults' table with the Obama administration in planning health care reform , for most of the medical profession, I think the designation of "on the menu" is more appropriate as it is for many citizens who were "happy with their doctors and health care plans". Maybe sometimes folks just thought they had a seat at the table or , even worse, maybe they got what they wanted.

Thursday, July 15, 2010

For a while it seemed only a few medical blogs were expressing concern about Dr. Donald Berwick's suitability to be the head of CMS. See here for one of Dr. RW Donnell's posting on that topic and here for one by Dr. Doug Perednia of the new blog Road to Hellth. Now others are joining it.

The prolific and widely read Dr. David Gorski has submitted a detailed discussion about Dr. Berwick expressing in part concern about Berwick's apparent support for unscientific alternative medicine .See here for the commentary. Additionally, Gorski makes the case, based on quotes from Berwick, that in some regards his views appear to be naive and out of touch with real world physician-patient encounters and relationships. Quoting Gorski:

Berwick strikes me as a very well-meaning person with some good ideas about how to make our health care system less rigid and more responsive to patients’ needs, both medical and nonmedical. Unfortunately, he also appears to be naive to the point of my wondering whether he has any clue what it’s like to practice medicine in the real world or even in the idealized world of academics.

I agree.A number of Berwick's comments appear very naive,unrealistic, and something more expected from someone not actually caring for patients than a physician with any recent background in patient care.As best I can tell he had not been practices medicine for a while.

There is a major disconnect between Berwick's expressed adulation of the NHS and his statement that rationing must be done with his views of patient centerness which he self describes as radical.

"In February of 2009, Dr. Berwick gave a 'keynote' address at the IOM and Bravewell Collaborative-sponsored Summit on Integrative Medicine and the Health of the Public. He shared the podium with Mehmet Oz, Dean Ornish, Senator Tom Harkin, and other advocates of pseudoscientific health claims. I wrote about the conference at the time, mainly to call attention to its misleading use of the term "integrative medicine": literature emanating from the Summit characterized it as "preventive" and "patient-centered," whereas the only characteristic that distinguishes it from modern medicine is an inclusion of various forms of pseudomedicine.I noticed that Dr. Berwick was on the speaker roster, which I found disappointing: I imagined that he had either gone over to the Dark Side or, perhaps, was sufficiently naive about the topic to have been duped; or, more likely, that he had cynically accepted the offer to further his ambitions."

Monday, July 12, 2010

Apart from some apparently radically contradictory expressed views on patient "centerness " and patients being in control ( see here for a discussion of some of his inconsistency) the newly appointed head of CMS, Dr. Donald Berwick, has made it clear what sort of medical system he would have for the United States.

What he wants is well explained in this commentary from National Review Online as is the authors' reasoning of why that sort of authoritarian central planing never seems to work. The following is from that article:Ideologues on the left favor a single-payer system for, well, ideological reasons of material egalitarianism. But for technocrats like Berwick, who shape the liberal policy consensus, the single-payer system is the most efficient way to manage health care. Top-down control, in their minds, ensures that every participant in the system serves the broader public good: hospitals and doctors only perform the tests and procedures they need to; private companies make enough money to get by, without excessive profits; and “integrators” mandate best practices for all parties based on the best available evidence.

From Berwick's extensive writing and speeches we see that he favors a system in which data is dispassionately collected,adroitly and in an unbiased manner analyzed and in the most scientifically validated method a cost benefit analysis is performed so that the proper testing, procedures and medications are dispensed in a fair, equitable, humane and compassionate manner. Mandated best practices would impose order on the chaotic unplanned, helter-skelter mess we have today. By the same token someone should impose order on the chaotic, unplanned mess that is our "grocery delivery"system. Getting food is even more important that health care. By that I mean the thousands of groceries across the country in which most of us find, most of the time, everything we want. and if we don't, we go to the store down the street.Contrast that with the iconic empty grocery shelves of the USSR which fixed the chaotic market with best practice central planning.

It is difficult to imagine that someone still thinks central planning is more efficient that market mechanisms.Most anti-markets theorists decry what they believe to be the lack of morality of markets while agreeing that markets are most efficient.

So what could be wrong with this technocratic approach? The NRO essay suggests the following for starters:

Even if you believe that technocrats could better organize our health-care system, Berwick’s approach only works if the narrow interests of Congressmen, labor unions, general hospitals, the AARP, etc., have no influence on the writing of law. No one who watched Democrats make the Obamacare sausage can harbor any illusions on this score.

In other words,it would work only if we change human nature and the folks in government ( both the legislative and the executive branches) miraculously are no longer vulnerable to the incentives and pressures and biases and,yes even self interest, that is the plight of the rest of humanity. Technocratic administration in theory and technocratic administration in practice could not be more different.

A second point from NRO's critique:

Technocrats may believe they can marshal statistics and analysis to optimize the health-care system, but they are not omniscient. Their analyses rely on too many assumptions and on unreliable data. This is why government programs always result in colossal amounts of waste, fraud, and abuse.

So, how well did the central planning work out in the USSR? Hint: There is no USSR anymore.Starvation and near starvation characterized both the Russian and Chinese central planning of farming.

Berwick longs for a situation in which "leaders with plans" can roll up their sleeves and get this chaotic,leaderless medical system on the right road. I can think of little worse that putting self anointed leaders with plans in charge of medical care or,for that matter, grocery distribution.

Saturday, July 10, 2010

H/T to Keithhennessey.com for calling attention to the fact that Dr. Donald Berwick did not reply to Senate Democrats questions regarding who funded his foundation, the Institute for Healthcare Improvement (IHI).See here.

The mainstream medical organizations seem to have nothing but praise both for Dr. Berwick's work and his institute.

If you visit the IHI website you will not learn about who funds the organization.You will learn that the IHI has quite a few vice-presidents for what that is worth.

I have no reason to believe that their activities are anything but those representing a sincere effort to improve medical care although I freely admit that I have not spent much time analyzing or learning about exactly what they have done. But the question remains- why are the donors' name(s) not made public.

This commentary, from the American Spectator (AS) appears to have answered some of the questions regarding funding and raises the issue of the dread conflict of interest (COI) in regard to Berwick and the IHI.

I was impressed with how lucrative it is have Berwick's job at the IHI and how well a number of their vice-presidents are compensated. If the facts are as they are claimed to be in the AS article, it seems like we have once again validated the Mafia rule of "follow the money" because managed care organizations and insurance companies contribute to the IHI. Could it be they may well profit from research on quality which just happens to find that less care is better and/or that there is much overuse and misuse in medical care.

Here is a quote from the NHS speech Dr. Berwick delivered:

In the United States, these hundreds of insurance companies have a strong interest in not selling health insurance to people who are likely to need health care. Our insurance companies try to predict who will need care, and then to find ways to exclude them from coverage through underwriting and selective marketing. That increases their profits. Here, you know that that is not just crazy; it is immoral.

There is a interesting contrast here.Very critical remarks about the U.S.health insurance industry are made by someone who, according to the American Spectator Article, received 2.36 million annually since 2008 in compensation from an institute which is to a significant amount funded by health insurance companies.

Why are these companies paying someone so well to travel the world and bad mouth them?

All of this is really the dogs barking while the caravan moves on.Obama has in place a staunch single payer advocate. A single payer is becoming more will likely to happen sooner rather than later if the debacle with Masscare is a precursor of what will happen to the insurance industry with Obamacare.

Thursday, July 08, 2010

President Obama has appointed Dr. Donald Berwick as head of CMS during Congress's recess .If you like central planning and the notion of redistribution of wealth, you should love Dr. Berwick at least if you believe he was sincere in his speech praising the National Health Service in Great Britain.But is there another side to his philosophy?

He said that we need "leaders with plans" to design and reform the U.S. health care system. He said that"excellent health care is by definition redistribution". See here for a portion of speech praising the British NHS for in which the "redistribution " quote appears.

He has expressed his "love" for the NHS which is well known for its particular form of rationing medical care. This poses an interesting and puzzling contrast with the following statement from his paper from Health Affairs (vol.28,no.4):

Evidence-based medicine sometimes must take a back seat. First, leaving choice ultimately up to the patient and familymeans that evidence-based medicine may sometimes take a backseat. One e-mail correspondent asked me, "Should patient ‘wants’override professional judgment about whether an MRI is needed?"My answer is, basically, "Yes." On the whole, I prefer thatwe take the risk of overuse along with the burden of givingreal meaning to the phrase "a fully informed patient." I contemplatein this a mature dialogue, in which an informed professionalengages in a full conversation about why he or she—theprofessional—disagrees with a patient’s choice.If, over time, a pattern emerges of scientifically unwise orunsubstantiated choices—like lots and lots of patients’choosing scientifically needless MRIs—then we should seekto improve our messages, instructions, educational processes,and dialogue to understand and seek to remedy the mismatch.For the same reason, I wish we would abandon the word "noncompliance."In failing to abide by our advice or the technical evidence,the patient is telling us something that we need to hear andlearn from. Honestly, how many of us have ever faithfully takena full ten-day course of a prescribed antibiotic or never consciouslyskipped a statin dose? Are we fools who did that? Or did wechoose that because of some sensible, local considerations ofbalance, convenience, or even symptom information that the doctornever had?

I would have liked to have heard his attempt to reconcile those views some of which sound like advocacy for ground up versus a top down control mechanisms with his affinity for the rationing activities of the NHS and his preference for leaders with plans to design the health care system but the recess appointment eliminates the need for Senate confirmation and the hearings that precede it.So we may never hear that.

Does Berwick believe the patient should call the shots or should the "leaders with plans" be the decision makers? It is hard to believe that in his beloved NHS a patient can get an MRI if she wants one or for that matter get certain cancer treatments? Perhaps he can miraculously merge those views which appear to be contradictory and the result of his leadership at CMS in the era of Obama care will be health care that is " generous, hopeful, confident, joyous and just " which are the words he used to characterize the NHS. What does it even mean to describe a health care system with as many problems as have been documented in the NHS as hopeful and joyous?

Sunday, July 04, 2010

There is benefit to make a law ambiguous-at least to the bureaucrats whose rule making will give that law operational meaning. There is benefit to a law which delegates to federal agencies the power to flesh out what a exhaustingly long and dense morass of legalese really means-at least to the lobbyists who represent the special interests who will benefit from the"proper interpretation" and implementation of the statute.

Such it is with PPACA aka Obamacare. Hat Tip to the The blog "Thinkmarkets .

" these reams of regulation are an epitome of vagueness...In the murk and the wide-open discretion given to bureaucrats lie gems for lobbyists. The White House and Congressional Democrats-even as they chided business lobbies-maximized the bill's scope and vagueness, laying the groundwork for massive growth in the crony system that intermingles government with private interests".

"Void for vagueness" is a legal concept that seems to particularly apply to criminal law and perhaps only to criminal law. In non criminal law vagueness seems to have become a virtue so that both sides in regard to particular legislation might think they have passed what they wanted and after passage the real meaning of the law is authored by various regulatory agencies and then the regulations themselves are often couched in another layer of vagueness allowing much interpretive leeway to those agencies.